Over several decades, medical ethics has played a central role in patient care and core principles have been developed to guide the physician-patient relationship. While it is true that medical ethics aims to protect all the parties involved in the doctor-patient relationship many problems continue to exist as difficult situations within the medical fraternity arise. More interestingly, the moral distress of physicians who care for critically ill patients, especially the geriatric population poses significant issues for those doctors that include burnout and depression. In this essay, I will discuss some of the findings related to the moral distress of clinicians and how the overall medical care system and society at large have approached it as well as some of the consequences of this phenomenon.
A recent study carried out by researchers from Regenstrief Institute, Indiana University School of Medicine, and Indiana University Health found useful information about moral distress amongst clinicians. They defined ‘moral distress’ as a condition related to burnout and depression. Their study suggested that in every 10 doctors, at least 4 caring for geriatric patients who need a surrogate decision-maker experienced “moral distress”. They also went further to explain that moral distress is an emotional episode in which a person feels restricted from acting on completely entrenched values, leading to the sense of placing one’s professional integrity at risk.
According to the researchers, “When hospitalized older adults have impaired cognition, family members or other surrogates communicate with clinicians to provide information about the patient and to make medical decisions for them. When working with these surrogate decision makers, physicians often encounter ethical challenges -- such as whether to continue life support or not -- that may cause them to experience moral distress with its potential negative consequences”. It is evident that the decision-making process for patients who are unable to have autonomy due to their illness is hard for those involved in providing care and has ultimately cultivated further the culture of depression amongst doctors according to a senior author Alexia Torke, M.D., associate professor of medicine at IU School of Medicine and Regenstrief Institute research scientist.
Conclusions drawn from the study at Regenstrief Institute stated the occurrence of physician moral distress was more likely if the doctor was male, an intern or other junior level doctor if the patient had advanced age, and finally, if decisions were necessary for life-sustaining treatments. In addition, the writers noted that doctors were less likely to go through moral distress when factors such as caring for ill patients living in a nursing facility, the doctor and family adequately discussed care options with the patient before losing their capacity to make decisions, and whether or not the physician and surrogate decision maker accepted the prescribed treatment.
Through this research, the authors identified that communication was the single and most critical factor in decreasing physician moral distress. They highlighted that a doctor’s moral distress decreased when the patient had clearly stated his or her choices through an advanced medical directive or even by word of mouth (which I think is quite risky due to its legal implications) before the critically ill patient lost their cognitive function and that the preferred measure was explicitly given in detail to the responsible clinician(s). The study concluded that a total of 362 surrogate decision-makers of geriatric patients who cannot make decisions and 152 doctors providing care for those people were interviewed. Overall, the conclusion drawn from the study was that those doctors’ moral distress came about when they felt that the primary care plan included more “life-sustaining treatment” for the patient than what was thought to be appropriate.
Another clear example of the increased prevalence of extraordinary physician burnout was during the COVID-19 pandemic. According to a publication from May 2021, a total of 20,947 healthcare staff from 42 organizations were surveyed, and amongst those participants, 38% reported anxiety/ depression, 43% suffered work overload, and 49% had burnout. This study concluded that stress scores were increased among nursing assistants, medical assistants, and nursing workers.
When looking at the consequences that may arise from clinician burnout, the most important aspect related to care in my opinion relates to patient safety. According to an article published in the Guardian in September 2022, physicians experiencing burnout are predisposed to incidents about a patient’s safety. The results, which were published in the British Medical Journal, have sparked new worries about the wellbeing and workload of physicians in the NHS in light of the mounting evidence that many of them are stressed out and worn out from excessive workloads.
A collaborative group of Greek and British researchers examined 170 prior observational studies examining the relationships between physician burnout, professional engagement, and patient care quality. The opinions and experiences of 239,246 doctors from the US, UK, and other nations in Africa, Asia, and other regions of the world formed the basis for those publications. They discovered that burnt-out medical professionals were twice as likely as their counterparts to have been engaged in patient safety problems, exhibit a lack of professionalism, and receive bad patient ratings.
One major issue facing NHS doctors is burnout. Based on responses from 67,000 medical professionals, the General Medical Council's most recent annual survey of aspiring physicians in the UK was released in July. It revealed that "the risk of burnout is now at its worst since it was first tracked in 2018" as a result of intense workloads that have been made worse by the Covid-19 pandemic. According to the medical regulator, 44% of trainees frequently felt "exhausted in the morning at the thought of another day at work," and 2/3 said they "always" or "often" felt exhausted after their workday.
Another aspect of clinician burnout that has been studied is the relationship that it has with
suicidality and although the evidence obtained from cross-sectional studies is unequivocal and states clearly that depression and burnout are directly related to suicide ideation among physicians, the general public still assumes that this incidence is still related to the strain placed on the healthcare system. With the current evidence pointing towards more and more doctors being mentally and physically impaired due to burnout, we can assume that the guiding principles of medical ethics that are set to protect physicians and patients will undoubtingly be motioned in hundreds of thousands or even millions of lawsuit action related to incidents stemming from burnout. With successful intervention from the medical system, government, and those who are active participants in the medical decision-making process, the incidence of physician burnout can be decreased.
Innovative solutions and laws tailored to supporting physicians and other specialists involved in critically ill patients should be sought to create a safe environment for doctors. Until this is not achieved, I fear that there may be a steady increase in doctors who lose their licenses and even become imprisoned under charges of manslaughter. In my opinion, medical ethics is a double-edged sword, working to guide and protect doctors but also functioning to annihilate healthcare workers.
In conclusion, medical ethics surrounds the medical decision-making process and governs the doctor-patient relationship, however, moral burnout experienced by clinicians and other health sector workers has had tremendous impact on physicians, ultimately resulting in patient safety being compromised. To ensure that this is avoided, regulating bodies in the health system, government and the general public should find plausible solutions to ensure that both the physician and the patient are protected in the long run.
